Our overall objective is to improve the quality, safety, and continuity of patient care during the transition from inpatient to ambulatory care by developing a model of effective communication between inpatient and ambulatory physicians. During the past several years, we have seen transitions in care become more frequent, resulting in increased opportunities for errors that may result in patient harm. Institutions struggle with challenges to provide care in complex delivery systems that include increasing the use of hospitalists and further decreasing the length of hospital stay. Furthermore, care teams are fragmented secondary to the resident work hour regulations. As patients enter the inpatient realm of care, they are often bewildered at the rapidity with which care is instituted and disoriented by the lack of a familiar decision-making guide, their primary care physician (PCP). These abrupt shifts in care delivery are compounded by the fact that often these patients have complex co-morbidities and often have low health literacy, making them exceedingly vulnerable to the fast-paced transitions in care. The presence of the PCP as a guide and adjunct to the inpatient team providing clinical care may alleviate patient fear and disorientation and assure continuity of care when the patient transitions back to the ambulatory care setting. Although current literature suggests that PCPs are currently unsatisfied with communication at transition points between ambulatory and inpatient care and that such communication is fraught with content omissions and not performed in a timely fashion, no work to date has delineated a content-driven strategy for improving and standardizing communication during these transitions. Specific aims: 1) Assess current methods of communication between inpatient physicians and PCPs during the inpatient-ambulatory transition and determine how that communication affects patient care; 2) Develop a model for effective inpatient physician - PCP communication; and 3) Design an intervention to evaluate the model for effective inpatient physician - PCP communication. PH Statement: Creating an effective model of communication between inpatient physicians and PCPs during times of patient transition has implications across a number of domains, including the assurance of patient safety, a patient-centered focus of healthcare delivery, and allocation and use of healthcare resources. [unreadable] [unreadable] [unreadable]